May 15, 2007 • www.familypracticenews.com Digestive Disorders 39 Physicians’ Views Differ on Diet’s Role in GERD

BY JOHN R. BELL cause a transient burning symptom in the identify foods that give you trouble, then meals close to bedtime and to avoid lying Associate Editor patient with esophagitis.” by all means avoid those. But I don’t specif- down immediately after eating. He cautioned that pH testing can be in- ically prohibit coffee or orange juice. And Regarding the role of NSAIDs in heart- atients with gastroesophageal reflux fluenced by these products. “During test- the idea that making orange juice a little burn or GERD, Dr. Spechler said that disease may ask about the effect of ing with a pH sensor, the ingestion of any bit less acidic in terms of heartburn—I find most studies have not shown NSAIDs to Pdietary acids or medications on their of these may produce an artificial lower- this a little difficult to believe.” exacerbate these conditions but cautioned disease, and despite the availability of “low ing of the pH that mimics reflux,” Dr. To qualify for a diagnosis of heartburn, that that at least one has shown that these acid” versions of coffee and orange juice, Castell said. the patient must report substernal dis- drugs may increase reflux. Thus “there are experts have different opinions on the im- Dr. Orlando emphasized that manufac- comfort that migrates in a superior direc- some concerns” about allowing patients pact of lifestyle factors in GERD. turers of “stomach friendly” products seem tion, Dr. Orlando noted. Stomach prob- with reflux to continue on NSAIDs. Dr. Roy Orlando believes that high-acid to be confusing GERD with the symptoms lems, such as gastritis or gastric ulcers, “If the pills get stuck in the esophagus, foods can contribute to existing problems, of heartburn, along with stomach distress. include “a whole host of additional signs they can be caustic; they can actually cause because his patients have consistently re- This may help to sell coffee and orange and symptoms,” he said. burns in the esophagus,” he explained. ported worsening of symptoms after con- juice, he said, but Aspirin in particu- Moreover, “there has been an association suming them. “There are many things that physicians should en- No proof exists that coffee lar is a common con- of strictures with use of NSAIDs. But in can be irritants, but it’s not all the time, and sure patients under- tributor to GERD, he general, we don’t see major problems any- it’s not in every person,” said Dr. Orlando, stand the differences causes GERD, ulcers, or said, given that so more. We’re seeing fewer strictures. The professor of medicine and section chief, between these ail- heartburn, but it certainly many people now medical treatments are so good that re- gastroenterology and hepatology, at Tulane ments. take it daily to protect stricting [NSAIDs] has become a very sec- University Medical Center, New Orleans. “The first thing can irritate the stomachs the heart. And be- ondary feature of care for the patient with As far as causation, however, “coffee in one needs to be alert of patients who already cause patients often reflux disease.” and of itself is not likely to be the cause to is the fact that experience irritation He said that his institution will soon pub- of a disease—the disease being reflux dis- when [patients] talk have those conditions. only after weeks or lish a study examining the effects of ease,” he said. “But if you have, or you de- about ‘stomach prob- months, they mistak- ibuprofen on reflux, in which the drug was velop, reflux disease, coffee could then be lems,’... [these] are not esophagus prob- enly attribute their symptoms to a bever- associated with an increase in reflux among an irritant. The same thing is true if you lems,” nor vice versa, he said in an inter- age or food, rather than the medication. some patients. have an ulcer of your stomach, or you view. “So one needs to be sure one is It would be rare to find a patient whose “It did not show an enormous increase have an irritation to the lining of your accurate when talking about stomach- current GI complaint was caused by some- in acid reflux, but it did show a significant stomach from something entirely inde- friendly products. If indeed the concern of thing he was drinking in the absence of increase,” he said. However, “we don’t pendent from the coffee you drank.” the person who was drinking a coffee was medication or underlying disease, Dr. Or- know if that’s ibuprofen specific or if that’s Thus, even though coffee and other bev- that the region just ...below the breastbone lando said, acknowledging that it could [caused by] all NSAIDs.” erages are not proved to cause gastritis, hurt or was sore or vaguely uncomfort- happen if a patient is experiencing unusual Dr. Orlando, however, indicated that he heartburn, GERD, or ulcers, such foods able, that wouldn’t be reflux, and that isn’t stress, such as a student studying for an im- believes lifestyle modification is an integral “can certainly irritate the lining of the heartburn.” portant examination who drinks many part of long-term treatment. After putting stomach” in people who already have one Dr. Stuart Spechler noted that there is a cups of coffee in order to stay awake. the patient on an H2 antagonist or a pro- such condition, according to Dr. Orlando. paucity of research about the effects of di- Dr. Spechler noted that the latest med- ton pump inhibitor for 4-8 weeks, the However, Dr. Donald O. Castell attrib- etary acids on GI and esophageal prob- ical treatments “are so good at stopping problem usually subsides. uted less importance to dietary acids in lems. “The data on the effects of coffee on stomach acid that, by and large, what we However, “if the patient hasn’t adjusted these diseases. “There are many things heartburn have been contradictory at best, used to call lifestyle modifications have re- their lifestyle, then I’ll guarantee that those that people eat or drink every day which and it just doesn’t seem to be a major play- ally assumed a very secondary or even ter- symptoms will come back again. So, in my have an acid pH level,” noted Dr. Castell, er,” said Dr. Spechler, the Berta M. and Ce- tiary role. ... Most of the [old] prohibi- mind, the medications are a crutch or a professor of medicine and director of the cil O. Patterson chair in gastroenterology tions—the dietary restrictions and things handle to capture the disease more effi- esophageal disorders program at the Med- at the University of Texas Southwestern like that—were based more on ideas than ciently, to get whatever damage may have ical University of South Carolina, Medical Center, and chief of gastroen- on proof.” Thus for patients who have no been done to the lining of the stomach Charleston, in an interview. “The most terology at the Veterans Affairs Medical worsening of symptoms after eating high- and the lining of the esophagus under con- acidic are carbonated beverages, followed Center, both in Dallas. acid foods, “I’m very lenient on diet for pa- trol, and to remove what may be provoca- by citrus products, fruits, wine, coffee, His advice to patients, like Dr. Orlando’s, tients with reflux disease.” tive things within the lifestyle—including and tea. By and large, these do not have is to avoid foods that aggravate symptoms. He added that physicians at his institu- diet—that may have contributed to the any real effect on GERD except they may “What we usually tell our patients is, if you tion also advise patients to avoid eating symptoms that you can control.” ■ Serum Markers May Help Diagnose Nonalcoholic Fatty Liver

BY HANNAH BROWN ing ELF [enhanced liver fibrosis assay, which looks at sev- marked increases in nonesterified fatty acid accumula- Contributing Writer eral serum biomarkers of fibrosis] might prove useful.” tion,” said Dr. Byrne. “So release of these from adipocyte When combined with age as a risk factor, the three mark- depots into circulation is abnormal in these patients. But G LASGOW, SCOTLAND — Serum fibrosis markers— ers assessed by the ELF blood test—hyaluronic acid, pro- we don’t know why [it is] associated with marked insulin currently used as a research tool—have high sensitivity collagen III amino terminal peptide (PIIINP), and tissue resistance.” and specificity for diagnosing more severe forms of non- inhibitor of metalloproteinase 1 (TIMP-1)—have around He presented research showing that a group of 1,974 alcoholic fatty liver disease, according to a presentation 85% specificity and sensitivity for moderate to severe type 2 diabetes patients with NAFLD had a significantly at the Diabetes U.K. Annual Professional Conference. NAFLD, he noted. higher prevalence of coronary, cerebral, and peripheral Diagnosis of the most severe forms of nonalcoholic fat- Alanine aminotransferase (ALT) and GammaGT, plas- cardiovascular disease than a group of 418 type 2 diabetics ty liver disease (NAFLD), which include the onset of ma markers currently used to help guide diagnosis for without fatty livers. “NAFLD is associated with increased steatohepatitis and subsequent fibrosis and cirrhosis, re- NAFLD, are not very accurate, according to Dr. Byrne. mortality, especially at the more severe end,” said Dr. quires measurement of the extent of inflammation and “ALT is an extraordinarily poor proxy. Both GammaGT and Byrne. “In these patients, even adjusting for all conven- the presence of fibrosis. Currently, only liver biopsy can ALT are in the normal range in patients who have quite tional cardiovascular risk factors and features of the identify patients with these symptoms; such patients extensive NAFLD when they get to biopsy,” he explained. metabolic syndrome, NAFLD is an independent cardio- must be managed more aggressively than patients with NAFLD is one of the most common forms of chronic vascular risk factor. If you find NAFLD, think accelerat- less severe forms of the disease, particularly with respect liver disease in developed countries, affecting 10%-24% of ed cardiovascular risk and treat aggressively.” to cardiovascular risk factors. However, biopsy is expen- the general population, especially people with type 2 dia- Treatment recommendations include initial weight sive and dangerous for the patient. betes. Liver damage is caused by accumulation of lipids, loss in patients that are obese; limited evidence suggests Dr. Christopher Byrne, head of the endocrinology and oxidative stress, and inflammation from the release of that pharmacologic therapy with glitazones also can be metabolism unit at the University of Southampton (Eng- proinflammatory cytokines. The associated marked insulin used to increase insulin sensitivity and decrease liver fat land), said he believes “in the future, noninvasive serum resistance in NAFLD has led some scientists to propose that content. “Glitazones show promise,” said Dr. Byrne. “A markers might be better. Research is beginning to sug- it might be a malignant form of metabolic syndrome. new indication for glitazone therapy may prove to be gest that within NAFLD, a scoring system such as that us- “Even adjusting for obesity, patients with NAFLD have NAFLD.” ■